AMA House of Delegates

AMA meeting: Delegates say don't shortchange specialists to fund care model

The AMA will ask CMS to help practices become patient-centered medical homes and to support models that allow non-primary care doctors to qualify.

By Emily Berry — Posted June 29, 2009

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In the discussion of how to pay for coordinated care under the patient-centered medical home model, the AMA House of Delegates agreed that primary care physicians should not be rewarded at the expense of specialists.

At its June Annual Meeting, the house voted to advocate that additional pay to physicians for operating a medical home should not come from a reduction to the pay of specialists. Delegates approved language that medical home payments not be subject to requirements for budget neutrality in Medicare, where an extra dollar spent somewhere means a dollar has to be cut elsewhere.

The house also approved recommendations that private plans and the Centers for Medicare & Medicaid Services develop one standard for a medical home, and that specialty practices as well as primary care practices should be able to serve as that home.

"Primary care needs more help. It just shouldn't come at the expense of specialists," said Kim Williams, MD, a cardiologist from Chicago and a delegate for the American College of Cardiology.

Spreading the benefit

Most of the delegates and others speaking in favor of adopting the language, which came from a Council on Medical Services report, were specialists. But primary care physicians who spoke offered no objections.

"It's the practice that's going to coordinate the care," said Dale Moquist, MD, a family physician from Sugar Land, Texas, and a delegate representing the American Academy of Family Physicians. "It's not specialty-specific."

The adopted recommendations call on the AMA to help create "incentives to design care coordination among providers who provide medical care for patients outside the medical home," which would spread the financial benefit of coordinated care among all of a particular patient's physicians.

The delegates' language also stated that the AMA should support the medical home model as a way to enhance care, but "without restricting access to specialty care."

"We do not believe that revenue should come out of specialists' pay," said Stephen Imbeau, MD, an allergist from Florence, S.C., and delegate from the South Carolina Medical Assn.

The recommendations delegates passed this year represent a continuation of a discussion that in 2008 resulted in the AMA's adoption of principles of the patient-centered medical home. Those principles originally were approved in 2007 by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians and the American Osteopathic Assn.

The principles include a medical home infrastructure that allows physicians to have more continuous contact with patients, to coordinate care better across the entire health system and to use more evidence-based medicine in clinical decision-making. In turn, physicians should receive additional payments that reflect the added value the medical home has for patients.

Funding medical homes a concern

Delegates were concerned with how CMS would pay for the care coordination provided by a medical home.

Citing already low pay rates from Medicare for physicians across specialties, delegates agreed that the AMA should push for CMS to exempt any patient-centered medical home payments from the Medicare budget neutrality requirement. The house called on CMS instead to rely on savings from better care coordination to fund incentive pay for medical homes.

"It's clear the savings of having a medical home and coordination of care will save Part A and other parts of Medicare, so there's plenty of money to pay for additional care," said James Bull, MD, a family physician from Silvis, Ill., and an alternate delegate from the Illinois State Medical Society.

Delegates also called on the Association to push CMS to help physicians pay for the up-front cost of becoming a medical home.

As many concerns as physicians have about how the medical home model will be used, some, such as Donna Woodson, MD, a family physician from Toledo, Ohio, and a delegate for the Ohio State Medical Assn., felt the time had passed for more study.

Dr. Woodson called for setting aside one resolution that asked the AMA to investigate further the implications of the medical home model, allowing the delegates to "move forward with this concept and not wait for another study." Delegates adopted the amended recommendations of the Council on Medical Service in lieu of the resolution requesting further study.

In his address to delegates at the Annual Meeting, President Obama didn't endorse the medical home concept explicitly, but he did talk about some elements of the model in outlining his vision for health system reform.

"We need to bundle payments so you aren't paid for every single treatment you offer a patient with a chronic condition like diabetes, but instead paid well for how you treat the overall disease," he said. "We need to create incentives for physicians to team up, because we know that when that happens, it results in a healthier patient. We need to give doctors bonuses for good health outcomes, so we're not promoting just more treatment, but better care."

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Primary care and specialties alike

After adopting criteria for patient-centered medical homes a year earlier, delegates this year turned their attention to ensuring that specialists aren't kept from benefiting from the new model. Here are recommendations adopted at the Annual Meeting:

  • That the AMA support the patient-centered medical home model as a way to provide care to patients without restricting access to specialty care.
  • That the policy includes the following statement: "It is the policy of our AMA that medical home participation criteria allow any physician practice to qualify as a medical home, provided it can fulfill the principles of a patient-centered medical home."
  • That the AMA urge the Centers for Medicare & Medicaid Services to work with the organization and national medical specialty societies to design incentives to enhance care coordination among providers who provide medical care for patients outside the medical home.
  • That the AMA urge CMS to assist physician practices seeking to qualify for medical home status with financial and other resources.
  • That the AMA advocate that Medicare incentive payments associated with the medical home model be paid for through system-wide savings--such as reductions in hospital admissions and readmissions (Part A), more effective use of pharmacologic therapies (Part D), and elimination of government subsidies for Medicare Advantage plans (Part C) -- and not be subject to a budget neutrality offset in the Medicare physician payment schedule.
  • That the AMA advocate that all health plans and CMS use a single standard to determine whether a physician practice qualifies as a patient-centered medical home.

Source: AMA

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Meeting notes: Medical practice

Issue: Guidance and policy is needed on the use and release of physician data.
Proposed action: A Board of Trustees report provides physicians guidance on the release and use of their data, including patient privacy safeguards, data accuracy and security safeguards, transparency requirements, review and appeal requirements, physician profiling requirements, quality measurement requirements and patient satisfaction measurement requirements. [Adopted]

Issue: Solutions are needed to address overcrowding in hospital emergency departments.
Proposed action: A Council on Medical Service report congratulates the American College of Emergency Physicians for developing solutions to the problem of overcrowded emergency departments. The report also supports collaboration between organized medicine and ED staff, and the dissemination of best practices, in efforts to reduce ED boarding and crowding. [Adopted]

Issue: Certain specialists are required to be in-house on a 24-hour basis at some hospitals. Some are not paid for this in-house coverage while others are.
Proposed action: The AMA work with the American Hospital Assn. to require the equitable treatment of all specialists required to provide in-house coverage. [Adopted]

Issue: The growth of the hospitalist movement has resulted in less hospital volume for some physicians. This has made it difficult for low-volume physicians to demonstrate clinical competencies in a hospital setting, as required by some credentialing rules.
Proposed action: The AMA adopt guidelines to assist medical staffs with credentialing and privileging physicians with low activity. [Adopted]

Issue: As employees of physicians, allied staff, including nurse practitioners and physician assistants, have little contact with the activities of organized medical staff, especially concerning patient care, safety, quality and ethical issues.
Proposed action: The AMA study how hospital medical staffs can involve allied staff in oversight activities. [Adopted]

Issue: Radiology benefit managers interfere with patient care and place an unnecessary burden on physicians and compromise patients' health by substituting tests or denying approval for tests.
Proposed action: Oppose routine denials or substitutions by RBMs working for third-party payers, study the prevalence of forced substitution of one study over the one requested, support the use of appropriate-use criteria developed by physicians with expertise in the specialty that pertains to the patient's condition. [Adopted]

Issue: Electronic medical records place the purchaser at the mercy of a vendor when the system needs fixing or upgrading. Open-source coding allows users to make changes and update as necessary.
Proposed action: Ask the AMA to develop open-source EMRs that meet "meaningful use" criteria, and make them available at a nominal cost to physicians. [Adopted]

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